What is asthma?
Asthma is a chronic lung disease in which the lungs overreact to various materials in the air and some respiratory infections. These "triggers" start inflammation in the airways, which causes two problems:
- Airways become more narrow, making it hard for air to move in and out. There is tightening of the muscles surrounding the airways (bronchoconstriction), extra mucus and swelling of the airway linings, which all add to the narrowing, which is called obstruction.
- Airways become super-sensitive or hyper-reactive to things that do not bother people with normal lungs. The "twitchy" lungs over-react even to cold air, exercise and smoke. The airway narrowing or obstruction and "twitchiness" cause the asthma symptoms to come in "waves" called flares or attacks.
Asthma is the most common chronic disease of childhood and the number one reason that children miss school, go to emergency rooms, and are admitted to hospitals. About five million American children are estimated to have asthma.
Children and adults with asthma are born with this problem. There are many different patterns of symptoms. Some people start having problems very early in life, others much later. Every asthma patient has asthma attacks, but some have more. Some patients have no problems between attacks or flares, but many have symptoms everyday. This is called "persistent" asthma, and the common cause is continuing exposure to allergy triggers and/or irritants like smoke.
With asthma, there can be years when all symptoms seem to have gone away, but everyone with asthmatic lungs is at risk for new problems. That's why all asthma patients and caregivers must know how to tell when someone with asthma is in trouble and how to care for problems associated with asthma, especially new flare-ups.
Some patients have a different, major lung disease (such as cystic fibrosis or bronchopulmonary dysplasia) in addition to asthma symptoms. Here we say the patient has that specific lung disease complicated by reactive airways, without using the term asthma.
Causes of asthma
People with asthma are born with airways that are super-sensitive to things, called triggers, that do not bother other people with normal lungs. These triggers start lung inflammation and asthma symptoms.
There are three major groups of triggers:
- Infections such as colds and sinus infections. Every asthma patient has a problem with this trigger.
- Allergies to pollen (tree, grass, weeds), molds, pets, dust mites and cockroaches.
- Irritants such as tobacco smoke and chemical fumes from heaters.
If asthma is not well controlled, simple things like exercise, weather changes, cold air and emotion (showing strong feelings like laughing and anger) can trigger asthma symptoms in an irritated lung.
Your child may have additional problems that can make asthma worse or harder to control. For example, gastroesophageal reflux can make the lungs more twitchy and tight.
Asthma can affect anyone; young or old, male or female, and people of all races and ethnic backgrounds. When one or both parents have asthma, a child has a greater chance of also having this lung disease. Still, many children develop asthma even though there is no family history of the disease.
The number of children with asthma continues to rise worldwide. We don't know why this is happening even though many asthma experts are doing research to try to find out. Some of the reasons for the increase may be that asthma is better recognized and diagnosed than in the past; increased air pollution; homes with less ventilation, more moisture, more indoor pets, and children spending more time indoors.
Signs and symptoms of asthma
The most important symptoms of asthma are:
- Cough: caused by the need to cough up mucus stuck in the lungs or from the irritation of the airways (twitchiness)
- Shortness of breath
- Chest tightness or pain
- Wheezing: the musical noise made by air coming out of narrow lung passages (like whistling).
Asthma attacks or flares come and go. When an attack begins, you will notice that your child's symptoms become worse and worsen rapidly. During an attack, you will likely notice that:
- The toughest symptoms occur after midnight, even though the problems of excessive cough, wheezing, shortness of breath, or chest pain are continuing all day. New night-time symptoms are signs that a new flare has started.
- The lungs are making lots of mucus. Your child may try to cough it out. Some children may even gag or vomit.
- The lungs become very twitchy. It will be a lot easier for cough, wheeze, shortness of breath or chest pain to come on with exercise, cold air, excitement, laughing or rough-housing.
If the attacks become more severe, breathing can be very difficult, like trying to breathe through a straw. Your child may become less active and appear tired.
It is important to know that some children do not show many symptoms even when their lungs become tight. If your child has such a tendency, your asthma specialist will help you learn about important symptoms to watch out for. These children will also need home peak flow monitoring, more frequent follow-up visits and lung testing.
Testing and diagnosis of asthma
Your child's asthma specialists will first look for classic asthma symptoms. It's important to know that not everyone with asthma will show wheezing. This is a common reason for failure to diagnose asthma. Also, when the airways get very narrow and tight, wheezing may stop. When this happens, the patient is worse, not better. Using "wheeze" alone to diagnose and follow asthma attacks can be unreliable and tricky.
Your asthma specialist will also look at how your child's symptoms cause a typical pattern of problems. Do they come in cycles or attacks? Do asthma medicines help relieve the symptoms? Sometimes this is enough to make the diagnosis.
We will also check for other conditions that might look like asthma. For example, we will evaluate your child for cystic fibrosis, disorders of the immune system and so on if your child's history and lung function tests hint that other problems might be present.
Lung tests may be important to help make the diagnosis. Spirometry can measure the obstruction in the airways and also show that obstruction can be relieved with asthma medicines. Other tests can show that the lungs are extra "twitchy." For example, lung function can be measured during exercise to look for obstruction. Finally, daily use of a peak flow meter at home can reveal that your child's lungs are going in and out of periods of obstruction or tightness either during attacks or even after exercise.
When asthma symptoms begin early in your child's life, such as the first year, a final diagnosis of asthma is usually not given until your child shows that the symptoms and attacks continue beyond the third year. As time goes by, your asthma specialist will review your child's symptoms and response to the prescribed medicines to better advise you about your child's final diagnosis and need for medicines.
Treatments for asthma
You will need to work closely with your primary care provider and asthma specialist team to control your child's asthma. Because asthma is a chronic disease, that means it's there every day, even when the child feels fine and has no symptoms.
One way to decide whether a child needs medicine daily is to go by the guidelines recommended by the National Institutes of Health. The guidelines recommend that if a child has symptoms more than twice a week and/or three or more flares within a year, then the child should be given daily controller medicine and monitored carefully.
Remember, guidelines are recommendations and each child should be viewed as an individual, so if you have questions about this, talk to your child's nurse practitioner or pediatrician.
Anti-inflammatory medicines for asthma
These medications help prevent and reduce the bronchospasm, swelling, extra mucus and "twitchiness" of the airways. When first started, they usually take time to work, sometimes weeks. They are used as a controller medicine to heal the lungs and prevent symptoms. They will do two things:
- Prevent every day problems during the times between flare-ups or attacks
- Reduce attacks, both the number and severity
Your child should not stop taking daily anti-inflammatory medications until your asthma specialist recommends it. If you stop these medicines after your child gains control, inflammation might return, along with symptoms and more asthma attacks.
Examples of controller medicines include inhaled steroids (e.g., FLOVENT and PULMICORT). There are also non-steroid drugs. These include "leukotriene modifiers" (SINGULAIR and ACCOLATE) and another group which includes INTAL (cromolyn) and TILADE.
Bronchodilators for asthma
These medicines work very differently from anti-inflammatory medicines. They open the airways by relaxing the muscles that surround them. There are two kinds:
- Short-acting bronchodilators are used for quick relief of asthma symptoms. They are also called reliever or rescue medicines. Examples include PROVENTIL and VENTOLIN (or albuterol), MAXAIR and the newer drug XOPENEX.
- Long-acting bronchodilators help control asthma symptoms because they stay active for a long time. These medicines do not act fast enough for quick relief, so they are not used in treatment of new attacks. Long-acting bronchodilators are not anti-inflammatory medicines when given by themselves, but they can help inhaled steroids to work when both are prescribed together.
Your asthma specialist team will discuss how these medicines work, when to use them, what to expect and how to recognize any side-effects. You will need to learn about them before becoming comfortable and knowledgeable enough to use them safely and effectively.
There are pros and cons that go along with each medication delivery method. Some children do well when given medicine by nebulizer machine and others are better with an inhaler with a spacer.
Whichever device is prescribed, it must be used correctly to be effective. For example, if you use a nebulizer, it should be used with a facemask or mouthpiece; don't just blow the mist into the child's face. Research has shown that metered dose inhalers work well for infants if used with a spacer and facemask.
When you get new equipment (such as an air compressor, filter, nebulizer tubing or mouthpiece) keep the instruction booklet and contact information for the manufacturer that supplied the equipment. The manufacturers of any piece of equipment will include information about how long it should last and how it should be cleaned.
To replace equipment, you will need a prescription. In order for the equipment to be covered by insurance, make sure that you order from a pharmacy or equipment company that has a contract with your child's insurance provider.
There are a few things you can do to help control inflammation in your child's lungs:
- Remove triggers of inflammation: do the best you can to improve your child's environment
- Have your child take enough anti-inflammatory medicines each day to control inflammation, even when she seems well
- Know how to treat new attacks right at the time they begin
Outlook for children with asthma
Asthma is not a condition that can be cured. With proper treatment for asthma, the goal is to have minimal or no asthma symptoms between flares. Children should also have fewer flares that are easier to control.
Your child may also have no limits in physical activities. When his asthma is effectively managed, he should be able to participate in exercise and sports. He should also eventually have fewer absences from school and work and the ability to self-manage asthma to the greatest extent possible.
You should know that asthma can be fatal, but fortunately this is rare. When asthma is the cause of death, it's usually because patients didn't take their medicines properly (when and how they were supposed to), or they didn't get help in time because they didn't take their symptoms seriously.
Follow-up care for asthma
When a child hasn't had a flare for a while, it's easy to assume everything is okay. But follow-up visits are important because asthma never really goes away. These appointments help you continue to learn about your child's pattern of asthma symptoms and how they might be changing. They can also help determine whether lung function tests are remaining stable or improving or whether daily controller medicines might need adjusting.
At follow-up visits, your primary care provider or nurse practitioner can also discuss any side effects and your concerns, make sure that the medicines are taken properly, and identify any problems you may have with getting the care you need: insurance coverage, access to appointments, ability to get medicines, organizing the medicine schedule. So it's important to keep those follow-up appointments as part of your on-going effort to keep your child healthy.
Reviewed by Sarah Taub, MD